No single person was responsible for the death of retired policeman Stephen Mangion, who collapsed at the Emergency Department of Mater Dei Hospital after complaining of chest pains, an inquiry headed by retired judge J.D. Camilleri has concluded.

But the Board of Inquiry found that the Floriana health centre, where Mangion went before being taken to Mater Dei, was only manned by doctors in training at the time.

And although triage and an ECG test were performed promptly when Mangion arrived at Mater Dei Hospital's Casualty Department, there was a shortage of cubicles and he was made to wait for two hours in the clinical area, where he collapsed and died.

The death of Stephen Mangion, 55, on August 27 had caused public outcry after complaints on Facebook that he had been made to wait for treatment. Mangion died from an aortic dissection after collapsing in the hospital’s emergency waiting room.

“Because of the complex and extensive nature of the underlying pathology, namely the extensive aortic dissection, nothing could have been done to avoid the demise of Mr Mangion,” the Camilleri report says.

A separate magisterial inquiry, headed by Magistrate Joe Mangion and revealed by Times of Malta on September 10 had similarly concluded that doctors and nurses who treated Mangion did nothing wrong and should not face criminal prosecution for his death. The magistrate had found no evidence of intent, negligence or delay by medical staff.  

The inquiry by Judge Camilleri was published by the Ministry of Health. The inquiry board said it found that there was no delay between the patient’s registration and triage at the Emergency Department and for an ECG to be taken following triage. There was no delay in the review of the ECG.

Patient could not be provided with immediate clinical care because no cubicles were available

However, since no cubicles were available he could not be provided with immediate clinical care and was made to wait for about two hours in the clinical area where he eventually collapsed.

”The inquiry board concluded that no person knew, or ought to have known, or caused an immediate risk to Mr Mangion’s life. On the contrary every healthcare provider did his best under the circumstances.

“However it seemed to the Board that, with the present system and available facilities, during exceptionally busy periods, ESI-1 (high risk) patients may have to wait for a long time for a cubicle, during which time they may end up not being adequately clinically reassessed.

Only doctors in training at Floriana health centre

The board noted that at Floriana health centre, where Mangion was taken before going to hospital, only doctors in training were seeing patients, and they had no easy access to receive advice from specialists in family medicine.

The fast track system was not operational at the time and 12-lead ECG machines were kept under lock and key and only made available if requested by the doctor. It was not clear if the responsible doctor was aware of this.

Lack of manpower, shortage of cubicles at the Emergency Department

At the emergency department, human resources were not sufficient to keep up with the workload.

Only one senior decision maker was available in Area 3, where Mangion was treated, and he had to deal with six critically ill patients, all requiring constant medical attention.

“Towards the end of the two hours of waiting in the clinical area, the patient (Mangion) was seen restless and in pain. He consulted with the nurses regarding his waiting time, he was given analgesia. This also called for clinical reassessment.

”The board said the number of cubicles was insufficient with the patient load on the day. The ED was overloaded with cases on a daily basis, resulting in long waiting times for patients and excess stress on the healthcare professionals," the board said.

The board made various recommendations, particularly in view of the shortage of cubicles at the emergency department.

“During waiting time, the patient would have benefitted from reassessment of his circulatory state, with monitoring of parameters and clinical signs. Pain relief and blood pressure-lowering treatment could have been considered.

"The fact that no cubicle was available should not have excluded the patient from receiving such basic clinical observations and possible initiation of treatment.”

The board therefore recommended that during very busy hours, a qualified person should be specifically allocated to go around the clinical area’s seating area and reassess whether the patients’ needs had changed, with the information being relayed to the lead nurse/lead doctor.

It noted the long waiting time between triage and medical contact, primarily due to the unavailability of a cubicle and limited human resources, and said it supported the ministerial proposal for the expansion of the Emergency Department as noted in the hospital’s action plan.

It also called for priority in the attraction and retention of ED personnel through various means, such as improving the work environment. 

See the report in full by clicking on the pdf link below.